Hospitals consider less-costly options for end-of-life care

The experience of death is changing in America, gradually shifting from costly, high-tech battles against death in hospitals into hospices that gently accept the inevitable end.

A new national database shows that 25 percent of Medicare patients died in a hospital in 2010, down from 28 percent in 2007. More than 47 percent died in hospice environments, often at home, up from 42 percent.

"We're seeing progress. Physicians are catching up with what patients want," said Dr. David C. Goodman, co-principal investigator for the Dartmouth Atlas Project, widely regarded as the best geographic analysis of the nation's variable medical resources.

"This shows how the health care system can change very quickly. We can look at the data and say, 'Through leadership and better planning, we can see pretty rapid change,'" he said. "That is a very hopeful sign of what we're capable of."

Santa Cruz, Calif., stands out for its low-intensity, high-touch standard of care: Its hospitals use less intensive care and more hospice than anywhere else in the greater Bay Area. In 2010, just 20.4 percent of its Medicare patients died in a hospital.

And it ranks with a handful of regions in the nation where patients saw fewer, not more, specialty doctors at the end of life. That is a measure of intensive care, because having many doctors poking, prodding and testing can be costly and physically onerous for the dying.

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Santa Cruz also is one of the few regions where patients' out-of-pocket costs actually declined, despite soaring national health care inflation. The Santa Cruz success story is attributed to an unusually tight bond among doctors, hospitals and civic groups in the geographically isolated locale. Additionally, its leading hospice has existed for 35 years, cultivating trust.

"We have a remarkably collaborative community that is able to meet each other at the edges, having tough conversations that involve high-quality, low-cost and practical solutions," said Michael Milward, CEO of Hospice of the Valley. "We talk to each other, so we know who can offer the best service for a patient and their family."

For more than two decades, the Dartmouth project's studies of variations in the use of medical resources in the United States have been influencing public policy. For this report, researchers analyzed Medicare's billing records between 2007 and 2010, the most recent years for which information was available, to identify differences among local, regional and national markets, and among hospitals and their affiliated physicians.

It found, for instance, that spending rates per chronically ill Medicare beneficiary in the final two years of life varied from a high of $112,263 in Los Angeles to a low of $46,563 in Minot, N.D. Nationally, Medicare spending for patients in the last two years of life increased more than 15 percent from 2007 to 2010.

In 2010, the highest rates of death in a hospital remained in regions in and around New York City, including Manhattan (43.7 percent), the Bronx (37.7 percent), East Long Island (37.4 percent), and White Plains (36 percent) -- though all these regions had lowered their rates since 2007. Chronically ill patients were far less likely to die in a hospital in Dubuque, Iowa (15.2 percent), Cincinnati (16.8 percent), and Fort Lauderdale, Fla. (17 percent).

The project has its critics, however, who say that more intense care and higher-spending hospitals may save lives.

Several trends are driving the growing use of end-of-life comfort care, said Victoria Emmons, CEO of Hope Hospice in Livermore, which had a 32 percent increase in patients between 2007 and 2010. The Internet offers new ways to learn about such services, she said. Aging baby boomers have found such intimate end-of-life care helped their parents, so they are using it themselves. And because there are a growing number of hospices, each does more publicity to stay competitive, she noted.

"There is more acceptance of it and greater interest nationwide," Emmons said.

Although hospice popularity is growing, its use in 2010 still varies widely. In the East Bay, Hayward's St. Rose Hospital transferred 28.5 percent of patients to hospice; its average Medicare spending, per dying patient, was $129,478. In nearby Castro Valley, 38 percent of Eden Hospital's patients went to hospice. It Its Medicare spending averaged $99,601.

Even within a city, there are differences in cost of care. In San Jose, Calif., Santa Clara Valley Medical Center and Good Samaritan Hospital are less than 10 miles apart, but Medicare spent an average of $21,000 more per dying patient at Santa Clara Valley, a public hospital where sicker patients are likely to go, than at Good Samaritan.

And even within a single medical center, practice patterns vary. John Muir Medical Center in Concord transferred 35 percent of its dying patients to hospice; the John Muir campus in Walnut Creek refers 50.7 percent.

"The trends are moving in the right direction overall," said Maribeth Shannon of the California HealthCare Foundation, which campaigns to improve end-of-life planning and care.

"But there is huge variation among individual hospitals, which is always troubling," she said. "Some are changing quickly and some are not making a lot of progress."